How to manage calcific tendinosis?

Management of Calcific Tendinosis

Conservative treatment should be the first-line approach for calcific tendinosis, with surgery reserved only for patients who have failed 3-6 months of appropriate non-surgical management. 1

Pathophysiology and Diagnosis

Calcific tendinosis (also called calcifying tendinitis) is characterized by calcium deposits within tendons, most commonly affecting the rotator cuff. The condition typically progresses through phases:

• Formative phase: Calcium deposition occurs within the tendon
• Resorptive phase: The body attempts to resorb the calcium deposits 2

Diagnostic Imaging

• Plain radiography: First-line imaging that can identify calcific deposits 1
• Ultrasonography: More specific (94%) than sensitive (58%) for tendinopathy; can show tendon thickening, decreased echogenicity, and calcification 1
• MRI: Useful for showing chronic degenerative changes and detailed anatomic information 1

Treatment Algorithm

1. Initial Conservative Management (First-Line)

• Relative rest: Reduce activities that worsen pain while maintaining some movement to prevent stiffness 1

  • Complete immobilization should be avoided to prevent muscular atrophy

• Cryotherapy: Apply ice through a wet towel for 10-minute periods to reduce pain and inflammation 1

• Pain management:

  • NSAIDs: Effective for short-term pain relief but do not affect long-term outcomes 1
  • Topical NSAIDs: May provide pain relief with fewer systemic side effects 1

• Exercise therapy:

  • Eccentric strengthening exercises: Proven beneficial for tendinosis and may reverse degenerative changes 1
  • Stretching exercises: Generally helpful for maintaining range of motion 1

2. Second-Line Interventions

• Corticosteroid injections: Consider if initial conservative measures fail

  • More effective than oral NSAIDs for acute phase pain relief
  • Caution: Do not inject directly into the tendon substance as this may weaken the tendon and predispose to rupture 1
  • Best used during the resorptive phase of calcific tendinosis 2

• Extracorporeal shock wave therapy (ESWT):

  • Safe, non-invasive treatment that may reduce pain and promote tendon healing
  • Appears effective but is relatively expensive 1

• Therapeutic ultrasound/Phonophoresis:

  • May decrease pain and increase collagen synthesis
  • Evidence for consistent benefit is limited 1
  • Some case reports suggest phonophoresis with cross-friction massage may help resolve calcific deposits 3

3. Surgical Management

• Indications: Consider only after failure of 3-6 months of appropriate conservative therapy 1

• Techniques:

  • Surgical removal of calcific deposits
  • Excision of abnormal tendon tissue
  • Longitudinal tenotomies to release areas of scarring and fibrosis 1

• Timing considerations:

  • Surgery is more appropriate during the formative phase
  • Rarely indicated during the resorptive phase 2
  • For chronic calcific tendinitis that doesn't respond to conservative treatment 4

Special Considerations

Phase-Specific Treatment

• Formative phase: Focus on pain management and maintaining function
• Resorptive phase: Consider aspiration and lavage of the deposit rather than surgical removal 2

Clinical Course

• Many cases (especially acute) resolve with conservative treatment alone 4
• Clinical improvement may take time, even after surgical intervention 4
• 2.7%-20% of calcific tendinosis cases are asymptomatic 4

Common Pitfalls to Avoid

1. Premature surgical intervention: Surgery should be reserved for cases that fail conservative management for 3-6 months 1

2. Direct tendon injection: Corticosteroids should not be injected directly into the tendon substance as this may weaken the tendon and increase rupture risk 1

3. Complete immobilization: This can lead to muscle atrophy and joint stiffness; relative rest with continued non-painful movement is preferred 1

4. Ignoring the phase of disease: Treatment should be tailored to whether the condition is in the formative or resorptive phase 2

5. Overlooking biomechanical factors: Addressing underlying biomechanical issues is important for long-term management 1